Heike Nolte
Thesis presented in partial fulfilment of the requirements for the degree of Master of Sport Science in the Faculty of
Education at Stellenbosch University
Supervisor: Dr Eileen Africa Co-supervisor: Prof Regan Solomons
December 2018
DECLARATION
By submitting this thesis electronically, I declare that the entirety of the work contained therein is my own, original work, that I am the sole author thereof (unless to the extent explicitly otherwise stated), that reproduction and publication thereof by Stellenbosch University will not infringe any third party rights and that I have not previously in its entirety or in part submitted it for obtaining any qualification.
December 2018 Heike Nolte
Copyright © 2018 Stellenbosch University
PLAGIARISM DECLARATION
I have read and understand the Stellenbosch University Policy on Plagiarism and the definition of plagiarism and self-plagiarism contained in the Policy [Plagiarism: The use of the ideas or material of others without acknowledgement, or the re-use of one’s own previously evaluated or published material without acknowledgement or indication thereof (self-plagiarism or text-recycling)].
I also understand that direct translations are plagiarism.
Accordingly, all quotations and contributors from any source whatsoever (including the internet) have been cited fully. I understand that the reproduction of text without quotation marks (even when the source is cited) is plagiarism.
I declare that the work contained in this thesis is my own work and that I have not previously (in its entirety or in part) submitted it for grading.
__________________ _________________
Heike Nolte Date
SUMMARY
Children with Childhood Apraxia of Speech (CAS) do not only have isolated speech and sound delays but teachers and parents often report motor co-ordination difficulties. The latter often leads to the child with CAS being clumsy. Although teachers and parents have reported motor co-ordination difficulties, research investigating the gross motor capabilities of children with CAS does not seem to exist. Not a single study could be found that investigated the effect of a gross motor intervention programme on children with CAS.
The main aim of the current study was to investigate the effect of a paired versus a small group gross motor intervention programme on selected pre-school children, pre-identified with CAS. Purposive sampling was used and consisted of participants (N=20), ranging between the ages of three and seven years. All the participants were from a primary school in the Bellville area in the Western Cape Province, South Africa.
The participants were randomly divided into paired groups and a small group by an external third party. Both the paired groups and the small group were evaluated at baseline-, pre- and post-test with the Movement Assessment Battery for Children 2nd Edition (MABC-2), and the Test of Gross Motor Development 2nd Edition
(TGMD-2). The evaluations took two weeks to complete and were conducted in two 45 minute sessions per week. The 12-week intervention programme was also presented twice a week, with each session lasting 45 minutes.
The researcher compared the results of the paired groups to the small group and concluded that the specific intervention programmes did not benefit either of the groups more than the other. Both the paired groups and the small group significantly improved their overall scores for the MABC-2 and the TGMD-2 after the 12-week intervention programme. Therefore, it could be speculated that the specific 12-week gross motor intervention programmes influenced the gross motor capabilities of the children pre-identified with CAS.
OPSOMMING
Kinders met Apraksie van Spraak (AvS) het nie net geϊsoleerde spraak en klank vertragings nie, maar onderwysers en ouers rapporteer dikwels motoriese koördinasie probleme. Laasgenoemde lei dikwels tot lompheid by die kind met AvS. Alhoewel onderwysers en ouers motoriese koördinasie probleme gerapporteer het, blyk dit dat navorsing oor die groot motoriese vermoëns van kinders met AvS nie bestaan nie. Nie ʼn enkele studie wat die effek van ’n groot motoriese intervensieprogramme op kinders met AvS ondersoek, kon gevind word nie.
Die hoofdoel van die huidige studie was om die effek van ‘n gepaarde- teenoor ‘n kleingroep groot motoriese intervensieprogram op geselekteerde voorskoolse kinders, wat vooraf met AvS geϊdentifideer is, te ondersoek. Doelgerigte steekproefneming was gebruik en het uit deelnemers (N=20) tussen die ouderdom van drie en sewe jaar bestaan. Al die deelnemers was leerders van 'n laerskool in die Bellville omgewing in die Wes-Kaap Provinsie, Suid-Afrika.
Die deelnemers is lukraak in gepaarde groepe en die kleingroep deur 'n eksterne derde party ingedeel. Beide die groepe was by die basislyn-, pre- en na-toets met die “Movement Assessment Battery for Children 2nd Edition (MABC-2)”, en die “Test
of Gross Motor Development 2nd Edition (TGMD-2)” geassesseer. Die assesserings
is in 45-minuut sessies, twee keer per week aangebied en het twee weke geneem om te voltooi. Die 12-week intervensieprogram is ook twee keer per week aangebied en elke sessie het 45 minute geduur.
Die navorser het die resultate van die gepaarde groepe met die kleingroep vergelyk en tot die gevolgtrekking gekom dat die spesifieke intervensieprogramme nie een van die groepe meer bevoordeel het as die ander nie. Beide die gepaarde- en kleingroep het hul algehele telling vir die MABC-2 en die TGMD-2 aansienlik ná die 12-week intervensieprogram verbeter. Daarom kan die navorser teoretiseer dat die spesifieke 12-week groot motoriese intervensieprogramme die groot motoriese vermoëns van hierdie deelnemers, wat vooraf met AvS geïdentifiseer is, beïnvloed het.
ACKNOWLEDGEMENTS
With the successful completion of this study, I would like to thank the following people:
My wonderful family who motivated and supported me throughout my journey with my Masters. Thank you for all your love and willingness to help wherever you could.
Dr Eileen Africa, thank you for all your time, knowledge, love and support. I could never have had the opportunity if it was not for you. Thank you for making this Masters possible.
Prof Regan Solomons, thank you for your collaboration, speedy and thorough feedback and assisting with the medical background to this study.
Prof Kallie van Deventer, for your outstanding technical and language editing.
Kinderkinetics Honours students of 2017, who evaluated and presented the intervention programmes to the children with love and passion.
Department of Sport Science at Stellenbosch University for allowing me to conduct the study and also for the use of your equipment.
Western Cape Department of Education for giving me permission to conduct the study at one of your schools.
The school for being interested in the study and giving me consent to conduct my study at the school.
The teachers for always being interested, for the encouraging feedback and the tremendous help with the discipline of the children.
Last but not least, thank you to each child for participating in the study and for always giving your best.
From the bottom of my heart, thank you to all the people who helped and made this study possible.
Thank you.
“Children are the world’s most valuable resource and its best hope for the future.” – John F. Kennedy
TABLE OF CONTENTS
P. DECLARATION i PLAGIARISM DECLARATION ii SUMMARY iii OPSOMMING iv ACKNOWLEDGEMENTS v CHAPTER ONE INTRODUCTION P. Background 1 Kinderkinetics ` 1 Methodology 2 Problem statement 2 Research design 3 Ethical considerations 3 Results 3 Discussion 3 Motivation 4 Keywords 4 CHAPTER TWO LITERATURE REVIEW P. Introduction 5Motor abilities, skills and learning 6
Executive functioning and motor skills 7
Gross motor deviations 8
Speech and language deviations 10
Relationship between motor skills and speech 11
CAS characteristics 12
Cause of CAS and diagnosis 13
CAS and DCD 14
Movement patterns of children diagnosed with DCD 16
Interventions 16
Early intervention 17
Frequency and duration of interventions 18
Paired gross motor programme 19
Small group gross motor programme 19
Specific intervention methods 19
Summary 22 CHAPTER THREE METHODOLOGY P. Introduction 23 Problem statement 23 Hypothesis 23 Null hypothesis 23 Research hypothesis 23
Main aim 24 Objective 1 24 Objective 2 24 Variables 24 Dependent variable 24 Independent variable 24 Confounding variable 24 Research design 24 Participants 27 Inclusion criteria 28 Exclusion criteria 28 Location 28
Data sources and data collection 28
Assessment tools 30
Movement Assessment Battery for Children 2nd Edition (MABC-2) 30
Specific test items 31
Scoring 32
Test of Gross Motor Development 2nd Edition (TGMD-2) 33
Specific test items 33
Scoring 34
Intervention programme 34
Process-oriented method selected 36
Product-oriented methods selected 37
Hypothesis statement 37
Programme outline 38
Statistical analysis 41 Data analysis and interpretation 41
Summary 41
CHAPTER FOUR RESULTS
P.
Introduction 42
Movement Assessment Battery for Children 2nd Edition 42
Test of Gross Motor Development 2nd Edition (TGMD-2) 42
Paired groups versus the small group 43
Comparing baseline- to pre-test results 45
Paired groups results 47
Small group results 48
Movement assessment battery for children 2nd Edition (MABC-2) 49
Total movement proficiency 49
Manual dexterity 50
Aiming and catching 51
Balance 52
Test of gross motor development 2nd Edition (TGMD-2) 53
Gross motor quotient (GMQ) 53
Locomotor 54
Object control 55
Descriptive results 56
Movement assessment battery for children 2nd Edition (MABC-2) 56
Test of gross motor development 2nd Edition (TGMD-2) 57
CHAPTER FIVE DISCUSSION
P.
Introduction 58
Paired groups versus the small group 58
Comparing baseline- to pre-test results 59
Paired groups and the small group 59
Movement assessment battery for children 2nd Edition (MABC-2) 60
Total motor proficiency 60
Manual dexterity 60
Aiming and catching 61
Balance 62
Test of Gross Motor Development 2nd Edition (TGMD-2) 63
Gross motor quotient 63
Locomotor 63
Object control 63
Descriptive results 56
Movement assessment battery for children 2nd edition (MABC-2) 65
Test of gross motor development 2nd Edition (TGMD-2) 64
Summary 66
CHAPTER SIX
LIMITATIONS, RECOMMENDATIONS AND CONSLUSIONS
P.
Introduction 67
Limitations 67
Participants and sample 67
Assessments 68
Intervention 68
Recommendations 68
Research 68
Participants and sample 68
Assessment 69 Intervention 69 Conclusions 69 Main aim 69 Objective one 69 Objective two 70 Summary 70 REFERENCES 71 ADDENDUMS 77
LIST OF ABBREVIATIONS
CAS Childhood Apraxia of SpeechSLI Speech Language Impairment
DCD Developmental Coordination Disorder FMS Fundamental Movement Skills
GMS Gross Motor Skills EF Executive Functioning
DLPFC Dorsolateral Prefrontal Cortex ADHD Attention Hyperactivity Disorder ASD Autism Spectrum Disorder
DAS Developmental Apraxia of Speech DVD Developmental Verbal Apraxia
ASHA American Speech-Language-Hearing Association SSDs Speech Sound Disorders
MSD Motor Sound Disorder DST Dynamic Systems Theory CNS Central Nervous Systems
CER Comparative Effectiveness Research
MABC-2 Movement Assessment Battery for Children 2nd Edition
TGMD-2 Test of Gross Motor Development 2nd Edition
AB Age Band
LIST OF FIGURES
P. 2.1 Speech sound disorders classification 10
3.1 Dynamic systems theory 35
4.1 Total motor proficiency for the paired groups and the small
group (MABC-2) 49
4.2 Manual dexterity for the paired groups and the small
group (MABC-2) 50
4.3 Aiming and catching for the paired groups and the small
group (MABC-2) 51
4.4 Comparing balance for the paired groups and the small
group (MABC-2) 52
4.5 GMQ for the paired groups and the small group (TGMD-2) 53 4.6 Locomotor scores for the paired groups and the small
group (TGMD-2) 54
4.7 Object control scores for the paired groups and the small group
(TGMD-2) 55
4.8 Descriptive results from pre- to post-testing for the MABC-2 56 4.9 Descriptive results from pre- to post-testing for the TGMD-2 57
LIST OF TABLES
P.
2.1 Altered terms for Dyspraxia and Apraxia 9
3.1 CER’s 7 proposed steps 26
3.2 Participants 28
3.3 Chronological age example 31
3.4 MABC-2 components and skills 32
3.5 Descriptive scoring: MABC-2 traffic light system 32
3.6 TGMD-2 subtest and skills 33
3.7 Descriptive interpretation of the GMQ 34 3.8 Outline of intervention programme 39 4.1 Comparing paired groups to the small group
(MABC-2 and TGMD-2) 44
4.2 Comparing baseline- to pre-testing results
(MABC-2 and TGMD-2) 46
4.3 Paired group’s pre- to post-test results (MABC-2 and TGMD-2) 47 4.4 Small group’s pre- to post-test results (MABC-2 and TGMD-2) 48
1
CHAPTER ONE INTRODUCTION
BACKGROUND
Childhood Apraxia of Speech (CAS) is a developmental disorder that is characterized by the inability to plan or programme an appropriate motor command specifically related to speech (Murray et al., 2014:486). Research concludes that parents and teachers often report co-occurring motor co-ordination difficulties that result in clumsiness (Tükel et al., 2015:1).
Gross motor function is pivotal to a child’s development and refers to the functioning of large muscle groups to produce co-ordinated, fluid movement. In a neuro-typical child, experiences and maturation positively impact the neuromuscular and musculoskeletal systems, which in turn develop and refine the child’s gross and fine motor skills (Utley & Astill, 2006:65). Although gross motor capabilities of children diagnosed with Developmental Coordination Disorder (DCD) has been researched extensively, research on gross motor capabilities of children with CAS is lacking (Wang et al., 2012:78). Furthermore, although DCD is co-morbid to Speech Sound Disorders (SSD), the gross motor capabilities of children diagnosed with CAS are under-researched (Gaines & Missiuna, 2006:325).
The current study aims to investigate the effect of a paired versus a small group gross motor intervention on selected preschool children, pre-identified with CAS. The specific gross motor intervention programmes were created by a Kinderkineticist.
KINDERKINETICS
Kinderkinetics is a professional field which aims to improve the gross motor skills of children (0 to 13 years old) through the stimulation, refinement and promotion of physical activity. The word can be broken up into two main components: 1) ‘Kinder’, which refers to the appropriate age range; and 2) ‘kinesis’, which refers to movement. Various children’s gross motor skills are enhanced through Kinderkinetics with scientifically based individualized intervention programmes. Physical activity is utilized in a fun way to attend to the movement needs of children (Pienaar, 2009:52).
Pienaar (2009:54) describes four main reasons why physical activity needs to be promoted in children. Physical activity:
1. promotes the growth of the muscular skeletal and cardiovascular systems;
2. maintains a healthy energy balance (healthy weight);
3. prevents risk factors, such as high blood pressure and abnormal lipid profiles; and
4. increases social interaction and mental health.
A study conducted by Van Biljon and Longhurst (2011:448) on neuro-typical pre-school children’s gross motor skills found that an eight-week Kinderkinetics programme significantly improved the gross motor skills of the children. They found that natural maturation was not a sufficient explanation for motor development and that complex motor skills need to be acquired (Van Biljon & Longhurst, 2011:448).
METHODOLOGY
Children pre-identified with CAS (N=20) were assessed at baseline-, pre- and post-test with the Movement Assessment Battery for Children 2nd Edition (MABC-2) and
the Test of Gross Motor Development 2nd Edition (TGMD-2). The participants were
randomly divided into two groups (paired- or small group). The paired group consisted of five paired participants (n=10) and the small group comprised of 10 participants (n=10). The 12-week intervention programme took place at the selected school and consisted of two 45-minute sessions per week.
Problem statement
During the literature review process (Chapter 2) it became evident that the gross motor capabilities of children, pre-identified with CAS, was under-researched. The current study, therefore, aimed to investigate the comparative effect of a paired- versus a small group gross motor intervention programme on selected pre-school children, pre-identified with CAS.
Research design
The current study followed a quasi-experimental design, made use of purposive sampling based on the characteristics of the population and no control groups were selected. Therefore, the influence on the uncontrollable variables could not be controlled (Joubert et al., 2016:274). The study was also based on a comparative effectiveness research design (CER) as there were only experimental groups and the CER design permits no control group. The aim of the study was to evaluate the effectiveness of the gross motor programme (Marko & Weil, 2012:425).
Ethical considerations
The proposal of the current study was approved by Stellenbosch University’s Research Ethics Committee (SU-HSD-004463). The Western Cape Educational Department, as well as the principal from the selected school provided written permission to conduct the study at the selected school. Each child completed an assent form with the help of the teacher and each parent or legal guardian completed a consent form. The parent or legal guardian was encouraged to ask any questions. The contact details of the main researcher were available on the consent form.
RESULTS
A mixed model repeated ANOVA was used with a 95% confidence level. There were significant improvements in both the paired- (p≤0.001) and the small groups (p≤0.001) in the total motor proficiency of the MABC-2. There were also significant improvements in both the paired- (p≤0.001) and the small groups (p≤0.001) in the overall gross motor quotient (GMQ) of the TGMD-2. After the intervention programmes, there were no significant difference (p≤0.48) between the paired- or small groups according to the GMQ of the TGMD-2. There was, however, a difference after the intervention between the paired and the small groups regarding the total motor proficiency of the MABC-2. This difference was not statistically significant (p≤0.07), although it was close to the significance level of 5%.
DISCUSSION
The results of this study support the null hypothesis that the outcome of the gross motor intervention would be the same for both the paired- and the small groups.
Both groups displayed a statistically significant improvement in their gross motor capabilities after the 12-week gross motor programmes. This study highlights the critical need for further research in the gross motor capabilities and how gross motor interventions can improve the quality of movement of children, pre-identified with CAS.
MOTIVATION
It was evident that children diagnosed with CAS have difficulties with gross motor skills. A simple task such as hopping and running seemed uncoordinated. These coordination difficulties should have a negative impact on their daily functioning and completing daily tasks. This raised a concern and is the main motivation behind this study.
Research lacks studies conducted on CAS children’s gross motor skills performance. No single gross motor intervention programme was identified. The need for research in this field was very clear as these children need early intervention. The significance of this study will help parents, early childhood developers, speech therapists and other professionals to be aware that children diagnosed with CAS might have difficulties with the planning and programming of gross motor coordination tasks.
The motivation behind this study is to help these children by understanding their movement demands and creating awareness about their gross motor difficulties. KEYWORDS: Childhood Apraxia of speech (CAS); motor co-ordination difficulties;
developmental coordination disorder (DCD); speech language disorders (SLI); gross motor capabilities; MABC-2; TGMD-2.
CHAPTER TWO LITERATURE REVIEW
INTRODUCTION
Childhood Apraxia of Speech (CAS) is a well-known developmental disorder of speech, which is characterized by the inability to plan an appropriate motor command (Murray et al., 2014:486). Children diagnosed with CAS have speech irregularities because of the inability of the brain to co-ordinate the function of the pharynx, mandible and tongue (Pema, 2015:46). A recent study by Tükel et al. (2015:1) stated that parents and teachers often report concurrent overall motor co-ordination difficulties in children with CAS, resulting in clumsiness.
MOTOR DEVELOPMENT, GROSS MOTOR SKILLS AND FUNDAMENTAL MOVEMENT SKILLS
Motor development can be defined as the progressive transformation of movement throughout an individual’s life. Motor development is perceived throughout one’s lifespan but is prominent in infants, young children and adolescents. These periods are characterized by the vast growth and maturation of the nervous system, which is needed to perform gross and fine motor skills (Van Biljon & Longhurst, 2011:441-442).
Fundamental movement skills (FMS) are developed in early childhood and are the basis for further gross motor skill development (Yu et al., 2016:134). FMS also result in better health outcomes, lower body mass index and improved cardiorespiratory fitness (Van Capelle et al., 2017:1). Early childhood has been identified as vital to acquiring and developing FMS. FMS are learnt, practised and re-enforced over time (Van Capelle et al., 2017:2), as demonstrated by the influence of experience and maturation on both the neuromuscular and musculoskeletal systems of the developing child (Kolesky, 2017:1). To execute specialized gross motor skills, a strong FMS foundation must exist (Yu et al., 2016:135).
FMS can be sub-divided into three main categories: 1) object manipulation; 2) locomotor skills; and 3) stability skills (Rudd et al., 2015:2). Object manipulation skills requires a child to manipulate or control (by using either their hands or feet), a given implement/object (balls, bats and racquets) (Van Capelle et al., 2017:2).
Examples of object manipulation skills include: catching; throwing; rolling; dribbling; hitting; and kicking a ball (Visscher et al., 2010:256). Locomotor skills are required to move one’s body from a certain point to another, which may be in any direction (Van Capelle et al., 2017:2). Locomotor skills include: crawling; walking; running; jumping; hopping; galloping; leaping; sliding; and skipping (Visscher et al., 2010:256). Stability skills are the ability to sense a shift in the relationship of the body parts as well as to alter these body parts to the changes to effectively balance. Examples of stability skills include: body rolling; bending; and twsiting (Rudd et al., 2015:2).
An additional key component of successful movement is the collective functioning of gross motor skills (GMS). GMS are the accumulation of FMS. The collective functioning of GMS can further be explained as the building up of certain GMS to execute movement patterns effectively (Platvoet et al., 2018:2). Gross motor function is pivotal to a child’s development and refers to the functioning of large muscle groups to produce co-ordinated, fluid movement. In a neuro-typical child, experiences and maturation positively impact the neuromuscular and musculoskeletal systems, which in turn develop and refine the child’s gross and fine motor skills (Utley & Astill, 2006:65). Further development of GMS is critical in order to perform more complex sequenced movement patterns (Van Capelle et al., 2017:2). However, GMS are not automatically acquired in children and require practise from a young age (Van Biljon & Longhurst, 2011:448). For any successful movement, planning and programming is needed. Without successful planning and programming of the movement, execution is difficult or impossible (Van Capelle et al., 2017:2).
MOTOR ABILITIES, SKILLS AND LEARNING
The terms motor abilities, motor skills and motor learning are often not clearly understood and it is sometimes difficult to distinguish between these three concepts. Infants are born with motor abilities; these abilities are genetic traits and determine to which degree the child would perform motor skills (Coker, 2009:15). The difficult part is to apply, correctly plan and program these abilities to become a motor skill (Van Biljon & Longhurst, 2011:441-442).
To acquire a motor skill, a four criteria model can be used: 1) it is always goal-oriented; 2) movements from the body/limbs are needed to achieve the goal; 3) the above mentioned movements are voluntary; and 4) the skill must be practiced in order to be learned (Coker, 2009:5). Motor skills need to be learnt in order to be maintained throughout one’s lifetime. However, not all motor skills are easy to learn or acquire because some motor skills are very complex (Van Biljon & Longhurst, 2011:441-442). To define the term motor learning is quite apparent; it is the permanent change in a child’s capabilities to perform/refine a motor skill due to the practice of the specific skill (Coker, 2009:4).
EXECUTIVE FUNCTIONING AND MOTOR SKILLS
Executive functioning (EF) is evident in infancy and continues throughout a normal lifespan (Leonard et al., 2015:202). EF is an overall term used to describe the complex cognitive processes used to perform difficult goal-directed tasks, such as specific motor tasks or tasks that require a high level of motor planning (Piek et al., 2003:1064). Planning is an important component of goal-directed movement, as complex movement requires organization, strategy and efficiency (Pennequin et al., 2010:108).
EF is an integration between several aspects (Piek et al., 2003:1066; Henry et al., 2012:37; Leonard et al., 2015:202). These aspects include:
strategically planning an action;
“switching” - being flexible and switching between tasks and thoughts; inhibiting certain inappropriate or specific responses; and
“working memory” - storing information whilst processing information from another task.
Research has shown a distinct relationship between EF and motor co-ordination and skills. This link between motor and cognitive development and functioning is because of spatial and temporal similarities (Schurink et al., 2011:727). The area of the brain required for executing motor tasks, called the right dorsolateral prefrontal cortex (DLPFC), is closely related to the cerebellum, which allows motor co-ordination (Leonard et al., 2015:202).
There is evidence that EF has been closely associated with a number of neurodevelopmental disorders, such as developmental coordination disorder (DCD), attention hyperactivity disorder (ADHD), autism spectrum disorder (ASD) and specific language impairment (SLI) (Leonard et al., 2015:202). EF is closely related to language as language development and speech has crucial role in cognitive self-guidance process. For instance, external vocalized speech helps a child to regulate thoughts and behaviour. This external vocalized speech turns into internal speech, which is a tool for self-guidance. This phenomenon has found to have a negative impact on the problem solving skills of the children (Kuusisto et al., 2016:128).
Schurink et al. (2011:727) suggests that further longitudinal studies and clinical trials should be implemented to further understand the relationship between motor performance and EF, as well as to investigate the effect that a motor-based intervention will have on these children’s EF.
GROSS MOTOR DEVIATIONS
Children with gross motor deviations have distinct motor characteristics, such as delayed motor milestone development, reflexes that are not integrated and laterality difficulties, all which require remediation and rehabilitation. They also have poor co-ordination, spatial- and body awareness and balance (Pienaar, 2014:116,120). Early identification of children with gross motor deviations are critical (Kolesky, 2017:7). Some gross motor deviations include apraxia and dyspraxia (Pienaar, 2014:118), the definitions of which are unclear. According to Vaivre-Douret et al. (2011:615) dyspraxia can be defined as “the failure to have ever acquired the ability to perform age-appropriate complex motor actions”. Pienaar (2014:118) defines dyspraxia as the inability to plan and execute motor tasks, usually known as poor motor planning. Vaivre-Douret et al. (2011:615) defines apraxia as “an acquired disorder that leads to the loss in the ability to accomplish previously learned skills”. Pienaar (2014:118), however, explains apraxia as a movement that has been planned but not executed.
The terms evolved over the years and has been used in different contexts as demonstrated in Table 2.1.
TABLE 2.1: ALTERED TERMS FOR DYSPRAXIA AND APRAXIA
Author and Year Name Definition
Ajuriaguerra & Stambak (1969)
Child dyspraxia with reference to constructional apraxia of adults
This was defined as the body integration interfering with spatial organization. Ayres et al. (1972)
Gubbay et al. (1979)
Developmental apraxia and agnosia
This was known to be the clumsy child.
Ayares et al. (1972) Sensory integrative dysfunction
Fails to perform motor tasks at the expected level. Adams (1983)
Densckla (1984) Cermak (1985)
Developmental dyspraxia Fails to perform motor tasks at the expected level.
Adams (1983) Clumsy child syndrome Fails to perform motor tasks
at the expected level.
De Lange et al. (1984-1985) Dyspraxia This disorder is a
developmental disorder and shows impairments in learning or performing motor tasks that are not from habitual nature. This is typically identified in
children.
This can be further explained as not ever having had the ability to execute the motor task.
Orton (1937)
De Lange et al. (1984-1985)
Apraxia This disorder is an acquired
disorder.
This can further explained as the loss of previously learned motor tasks.
Laszlo et al. (1988) Perceptual motor dysfunction Fails to perform motor tasks at the expected level.
Polatajko et al. (1995) Developmental Coordination Disorder (DCD)
Collection of conditions where clumsiness and developmental dyspraxia are present.
Kadesjo (1999) Disorder of attention and motor perception
Fails to perform motor tasks at the expected level.
Miyahara & Register (2000) Physical awkwardness Fails to perform motor tasks at the expected level.
Gibbs et al. (2006) Minimal brain dysfunction Fails to perform motor tasks at the expected level.
Speech and language deviations
Dyspraxia and apraxia are not only limited to motor functioning, but also associated with speech and language difficulties. Apraxia on its own is a very diverse disorder and can further be divided into eight sub-types: ideomotor apraxia; ideational/conceptual apraxia; buccofacial/orofacial apraxia; constructional apraxia; gait apraxia; limb-kinetic apraxia; oculomotor apraxia; and apraxia of speech (Pema, 2015:47). An example of such a disorder is Childhood Apraxia of Speech (CAS), formerly known as Developmental Apraxia of Speech (DAS) (Murray et al., 2014:486), or Developmental Verbal Dyspraxia (DVD) (Pema, 2015:46). In 2007, the American Speech-Language-Hearing Association (ASHA) adapted the term CAS (Souza et al., 2009:76).
Children diagnosed with CAS shows signs of impaired consistency and accuracy of speech movements in the absence of any neuromuscular deficits (Gubiani et al., 2015:611). CAS falls under the umbrella term, speech sound disorders (SSDs) (Tükel et al., 2015:1). In Figure 2.1, SSDs are classified into three main groups, namely: 1) Speech Delay; 2) Speech Errors; and 3) Motor Speech Disorders (MSD). MSD can be further classified into three main categories, namely: 1) dysarthria; 2) apraxia of speech; and 3) MSD not otherwise specified (Maas et al., 2014:197).
FIGURE 2.1: SPEECH SOUND DISORDERS CLASSIFICATION
CAS, however, has three distinct characteristics which distinguish it from other speech/language disorders, i.e.: 1) unpredictable vowel and constant errors in repeated words; 2) lengthened co-articulation transition between sounds and syllables; and 3) inappropriate prosody (Pema, 2015:48). MSD, is specifically associated with motor planning and programming difficulties (Maas et al., 2014:197). SSDs Speech Delay MSD Dysarthria Apraxia of speech MSD not otherwise specified Speech Errors
Developmental Co-ordination Disorder (DCD) is another clear example of a motor deviation with a prevalence of 10% (Gibbs et al., 2006:535). DCD is chronic and a predominantly permanent neuro-motor impairment (Debrabant et al., 2016:21). This gross motor deviation negatively affects the performance of fine and gross motor skills and motor co-ordination (Prunty et al., 2013:2927). DCD is often co-morbid to disorders, such as Attention Deficit Hyperactivity Disorder (ADHD) and other learning disorders (Hemmati et al., 2008:5). In the literature, DCD is sometimes considered to be synonymous with dyspraxia (Gibbs et al., 2006:534). The American Psychiatric Association considers a diagnosis of DCD only when the following is presented: 1) motor coordination daily activities is considerably lower as expected for age; 2) above mentioned motor difficulties interfere with daily activities and academic success; 3) coordination difficulties are not due to medical conditions; and 4) if mental retardation is diagnosed, the motor difficulties is in excess (Gibbs et al., 2006:535).
RELATIONSHIP BETWEEN MOTOR SKILLS AND SPEECH
During early childhood it is evident that children acquire motor and language skills at a rapid pace. This acquisition of skills is not just due to development but also due to the environment. Certain gross motor skills develop prior to communication skills. Thus, it has been debated that “object placement” is a precondition for developing language. Paradoxically, delayed communication has also been found to be a risk factor for motor difficulties later in life. Some studies have shown that half of pre-school children suffering from language delays develop motor delays and difficulties later in life (Wang et al., 2012:77).
In the available literature it is evident that there is a clear relationship between motor and speech domains of higher cortical learning (Visscher et al., 2010:254). Developmental delays in one domain often correlates with developmental delays in another. These findings can easily be validated from a neuropsychological perspective (Wang et al., 2012:78). The main structures of the brain causing problems in both the motor and speech domains are the basal ganglia and the cerebellum. These structures play a critical role in the fluency and co-ordination of movements, and damage to these structures may affect the control and execution of motor and speech movements (Visscher et al., 2010:254). Furthermore, children
with developmental speech and language disorder (CAS) may have basal ganglia and cerebellum dysfunction, which explains why these children struggle to execute fluid and co-ordinated movements (Visscher et al., 2010:254).
Wang et al. (2012:78) reports three main findings between motor skills and speech: 1. a relationship between communication and motor skills;
2. communication and motor skills are to some degree stable over time; and 3. the one skill predicts the other.
Wang et al. (2012:78) reports on his three main findings and suggests that there is a strong association between motor and communication skills in children. They also concludes that literature lacks in-depth simultaneous research in all three of the above-mentioned associations.
Communication and motor skill delays have been shown to predict psychopathological problems later in life, therefore, the urgent need to better understand the relationship between communication and motor skills (Wang et al., 2012:77).
CAS CHARACTERISTICS
CAS has a suggested incidence rate of 3 to 5% in children (Maas et al., 2014:197), which is 3 to 4 times more common in boys than girls (Tükel et al., 2014:1). Even though CAS is more prevalent in boys, girls have a more severe presentation of CAS (Souza et al., 2009:76). Some studies suggest that 40 to 90% of children diagnosed with speech/language disorders show signs of general motor co-ordination and manual dexterity difficulties (Gaines & Missiuna, 2006:326; Teverovsky et al., 2009:100).
Teverovsky et al., (2009:99) reported that CAS is often accompanied by impairment in far greater domains than just speech and language. Four functional problems in children with CAS have been identified by Teverovsky et al. (2009:99):
1. cognitive and learning problems; 2. social communication difficulties; 3. behavioural dysregulation; and
4. other oral motor problems.
According to Souza et al. (2009:77-78), CAS can be identified by the following five characteristics during a child’s development:
1. during the pre-verbal period, a CAS baby might seem quiet. They do not engage in any voice playing;
2. in children with CAS, the period for first word emission can vary from 19 months to 4 years. The average age for a CAS child to combine words might only happen between the age of 33 months and 7 years;
3. a child diagnosed with CAS shows no structural abnormalities or paralysis. They have normal hearing, use their face to show expressions, make non-verbal sounds and use words on their own;
4. as stated before, children diagnosed with CAS rarely only have difficulties in the motor programming of words. They often have difficulties or delays in language development (also presented in written language); and
5. the diversity of the characteristics of children diagnosed with CAS might be the reason that CAS is often misdiagnosed or under diagnosed.
Two characteristics of CAS where there is consensus, is that its onset is during early childhood and that it takes a long time to normalize (Souza et al., 2009:78). Children diagnosed with CAS were also found to have co-existing medical conditions such as hypotonia and sensory integration disorders. Some children were also diagnosed with developmental or mental health disorders, such as ASD and ADHD (Teverovsky et al., 2009:99).
The above-mentioned medical, developmental and functional co-existing difficulties stress the fact that these children have to undergo a comprehensive evaluation by a multidisciplinary team of clinicians and that a multidisciplinary team of therapists are needed to implement the interventions (Teverovsky et al., 2009:100).
CAUSE OF CAS AND DIAGNOSIS
As with most other neurological and behavioural disorders, the cause for CAS is still widely unknown. There is some evidence that genetics might play a key role. The FOXP2 gene is expressed in the cortex, basal ganglia, thalamus and cerebellum,
which are all areas associated with sensory and motor processing (Souza et al., 2009:78).
There is no formal gold-standard test yet to diagnose CAS. Differential diagnosis of CAS is an ongoing problem and leads to difficulties when trying to isolate specific diagnostic criteria (Tükel et al., 2015:2). Researchers, however, have found that combined methods should be used when diagnosing a child with CAS. An example is to use clinical assessments (by observing the child) and formal evaluations (with protocols which are proven to be valid and reliable) (Gubiani et al., 2015:614).
Some developmental speech/language disorders might be detected at a very early age but many mild to moderate developmental speech/language disorders can only be reliably diagnosed by the age of five years (Gaines & Missiuna, 2006:329). A study found that there is a core motor deficit in manual motor planning and co-ordination problems seen in DCD and CAS (Tükel et al., 2015:2). Careful observation of motor co-ordination may, therefore, assist the diagnosis of CAS in children.
Therefore, a specific researcher describe CAS to occur in three specific settings (Pema, 2015:50):
1. neurological impairment: when CAS is caused by infection, illness, injury or abnormality at birth or during the pregnancy;
2. complex neurodevelopmental disorder: that can be secondary to a genetic, metabolic or mitochondrial disorder and is then known as CAS; and
3. associated disorder: CAS might occur in disorders such as autism, fragile X, galactosemia, epilepsy and chromosome translocations.
CAS AND DCD
Specific language impairment (SLI) is a developmental disorder diagnosed in children. It is debatable whether children’s diagnosis with SLI is isolated to only having difficulties in the speech and language domain, or whether it is part of a broader spectrum of delay (gross motor delay) (Flapper et al., 2013:756). An example of such a developmental disorder, specifically in the motor domain is DCD.
DCD is known to be a co-morbidity of speech/language learning disabilities (Gaines & Missiuna, 2006:325).
Flapper et al. (2013:760) used the MABC-2 to measure the gross motor proficiency of children diagnosed with SLI and DCD. They found that 66% of the subjects had motor problems as they scored in the lowest 5th percentile of the MABC-2. They also
screened the children diagnosed with SLI for possible DCD by using the Developmental Co-ordination Disorder Questionnaire (DCDQ). These researchers found that 32.3% of children diagnosed with SLI were at risk for DCD according to the DCDQ. The co-morbidity of DCD was found throughout the spectrum of SLI and the conclusion was made that children diagnosed with SLI do not only struggle in a single domain, but that they might struggle in the motor developmental domain as well. It is, therefore, suggested that children with any speech or language disorder be screened for DCD (Flapper et al., 2013:761).
Four main explanations for the co-morbidity of DCD and SLI have been identified and includes the following (Gaines & Missiuna, 2006:326):
1. problems with generalization and praxis; 2. cerebellar deficits;
3. inter-hemispheric deficits; and 4. atypical brain development.
McCormack et al. (2011:1328) researched the association between communication impairments and children’s activity and participation. They concluded that children with a communication disorder have slower progression in reading, writing and overall school achievement. These children also reported more bullying, poor peer relations and less enjoyment of school activities. Therefore, these children exclude themselves from participating in activities (inside- and outside the classroom). Not only is this reported by the parents and the teachers but by the children themselves (McCormack et al., 2011:1328). Children with SLI are acutely aware that they are different to their peers and might affect their body image and self-esteem. Interventions should, therefore, focus on physical therapy, the environment, as well as their self-esteem (McCormack et al., 2011:1336).
MOVEMENT PATTERNS OF CHILDREN DIAGNOSED WITH DCD
Due to poorly-refined motor skills, children diagnosed with DCD co-ordinate their actions differently and have less advanced movement patterns (Utley & Astill, 2006:79). DCD can be diagnosed in a child as early as five years old (Wilson et al., 2009:185). Some studies classify the movements of children diagnosed with DCD as slower, with poor accuracy, less precise and less consistency (Farhat et al., 2016:11). It was also found that neuro-typical children have stable movement patterns, whereas children with DCD have unstable movement patterns (Utley & Astill, 2006:76). This instability of movement patterns may constrain children with DCD to perform more complex co-ordination patterns such as planning and executing complex motor tasks (Utley & Astill, 2006:79).
Fong et al. (2011:2615) investigated the Classification of Functioning, Disabilities and Health (ICF) model and concluded that there are many factors that contribute to the participation level of individuals, including physiologic impairments, such as motor deficits. Children diagnosed with DCD have been found to have a tendency to evade physical activity or completely withdraw themselves from physical activity (Yu et al., 2015:46). Not only was the participation level of DCD children lower, but the intensity at which these activities were performed were much lower as to their neuro-typical peers. This may be better explained by the fact that DCD children’s movement patterns are not efficient, and therefore, expend more energy and fatigue quicker (Fong et al., 2011:2620).
INTERVENTIONS
Gross motor intervention programmes and research thereof for children with speech and language disorders, more specifically CAS, is lacking. High quality intervention trials are required to determine which interventions are most effective at improving gross motor skills of children with gross motor disorders (Lucas et al. 2016:206).
A variety of intervention programmes have been identified by researchers that improve the motor co-ordination of children diagnosed with DCD. However, it is important to stress that DCD in correlation with CAS is a diverse disorder (Brenner, 2008:9). To find one specific intervention programme, is near impossible because no child with a developmental disorder exhibits the same difficulties in motor
co-ordination. This emphasizes the crucial need for intervention programmes (Chia et al., 2012:268).
Early intervention
Speech and language disorders are notoriously very difficult to treat. Not only are these disorders difficult to rehabilitate but in general the therapy takes long (Souza et al., 2009:79).
There is a considerable amount of evidence to show that children with co-ordination disorders do not ‘mature out of’ their poor execution of motor skills. It is shown that the motor difficulties that children with co-ordination disorders experience, can persist into adolescence (Yu et al., 2016:135). It has also been found that the motor skills delay in children with developmental speech and language disorders have not disappeared and that these children have not ‘caught up’ to their neuro-typical peers by the age of nine. This provides and stress the opportunity for early intervention (Visscher et al., 2010:257). Interventions should, therefore, focus on the prevention of physical activity withdrawal and poor motor abilities (Fong et al., 2011:2621).
Movement difficulties and delays should be identified in the early developmental phase so that early intervention can take place to minimize and correct these difficulties and delays (Fannin, 2015:41). Early intervention is a critical part of a child’s journey to improve their motor co-ordination and active daily functioning so that a healthy lifestyle can be maintained throughout their lifetime (Utley & Astill, 2006:80). It has also been suggested that early and more frequent interventions leads to larger developmental benefits (Fannin, 2015:41). It is, therefore, necessary to take into account intervention length and frequency because continuous practise of skills will reinforce the neurological pathways so that the skill will become involuntary (Fannin, 2015:41).
Markgraaff (2010:29) emphasizes that creating an intervention programme for children with developmental delay is challenging as each child is unique. This researcher also describes seven “building blocks” of motor function and stresses the fact that each intervention should consist of these seven blocks (Markgraaff, 2010:29):
1. muscle tone; 2. muscle strength; 3. gross motor skills; 4. fine motor skills; 5. motor planning;
6. sequencing and speed of movements; and 7. sensory integration.
Frequency and duration of interventions
There is no gold-standard regarding the frequency and duration of intervention programmes (Van Capelle et al., 2017:7). A specific study found a significant intervention effect when studying the number of sessions per week. They found that who received the intervention once a week had more improvement in their motor development than those children who only received the intervention every three or four weeks. This emphasize the importance of continuous interventions (Fannin, 2015:41).
Markgraaff (2010:30) reports that a 5 week intervention programme with two sessions per week (30 minutes each) is not sufficient for significant improvements of motor proficiency in children diagnosed with DCD. It has been found, however, that a 30-minute intervention session four to five times a week has a significant effect on children’s FMS (Van Capelle et al., 2017:7). The duration of intervention programmes vary from six weeks to 12 weeks (Kolesky, 2017:20). Another study also support these findings that a six- to 12 week motor skills intervention can change a gross motor delayed child to a gross motor competent child (Brian & Taunton, 2018:223).
Intervention therapies should be specific to the skill that needs improvement and should encourage regular fun physical activity (Lucas et al., 2016:194). Two main strategies to be used is paired and small group interventions. Both these intervention strategies have their own set of pro’s and con’s. Research lacks a comparison between the above mentioned intervention strategies.
Paired gross motor programme
A paucity of research exists for paired gross motor skill programmes for children diagnosed with CAS or related motor co-ordination disorders such as DCD. It has also been suggested that CAS should be seen as a spectrum and that children differ in their developmental delay, providing evidence for a paired intervention programme to improve motor functioning and co-ordination (Markgraaf, 2010:29).
Individual interventions seem to be used more frequently in practice by speech- and occupational therapists because it is seen to produce more benefits. Individual programmes benefit the child because it is more specialized, created according to their specific developmental needs and eliminates the possibility of misunderstanding. The limitation of this type of intervention is that it does not allow social participation or even inter-peer competition. However, a paired intervention has the benefit of an individualized more specialized intervention with the advantages of inter-peer competition (Fannin, 2015:42).
Small group gross motor programme
Group intervention programmes may also be effective as they provide a social component and decreases the anxiety that the child might feel (Fannin, 2015:42). Children in a group setting will not have the feelings of isolation, compared to children in an individual programme. Group interventions have been found to have a competitive aspect which increases performance. Conversely, if it is not well-organized and the presenter cannot control the large amount of children, the intervention will not be beneficial and the focus will merely be on the ability to win. An inexperienced presenter might also have difficulties monitoring all of the children at the same time (Kolesky, 2017:23). It has been suggested that group therapy is more sufficient, effective and favourable (Morton, 2015:11).
Specific intervention methods
The main goal of an intervention method is for the child to reach their optimal movement potential but at the same time minimize their movement difficulties or delays (Markgraaff, 2010:32). Therefore, early interventions are critical (Utley & Astill, 2006:80). It is, however, important to keep in mind that movement disorders are very heterogeneous and that no child is the same. No single intervention method can be used as a gold-standard. Conversely, without intervention the child will
continue to exhibit motor skills difficulties and delays (Markgraaff, 2010:32).
According to literature, there are three main methods to intervention: 1) process-oriented/bottom-up; 2) product-oriented/top-down; and 3) integrated. Each method of intervention are further sub-divided (Pienaar, 2014:218).
1. Process-oriented method/Bottom-up approach (Peters & Wright, 1999:204): A. sensory integration intervention method;
B. perceptual-motor intervention method; and C. kinaesthetic intervention method.
2. Product-oriented method/Top-down approach (Miller et al., 2001:186): A. cognitive-motor intervention method;
B. cognitive-strategies based intervention method; and C. task specific intervention method.
3. Integrated method (Pienaar, 2014:226):
a. an integration of the above mentioned methods.
The process-oriented method mainly focuses on the intervention of the underlying sensory systems. This method does so by the transfer of sensory information that is interpreted and organized by the central nervous system, to form a movement pattern (Peters & Wright, 1999:204). The belief in this intervention method is that if the underlying processes improve, it will improve the performance of skills that rely on these processes (Markgraaff, 2010:32). The process-oriented method can further be divided into different approaches (Pienaar, 2014:218-221):
1. sensory integration intervention approach; 2. perceptual-motor intervention approach; and 3. kinaesthetic intervention approach.
The product-oriented method focuses on problem-solving skills. Underpinning this intervention method is acquiring specific common skills, using and altering these skills to execute more complex movement patterns (Markgraaff, 2010:32). This method ensures that motor skills are acquired through the interaction of many
internal and external systems of the child (Miller et al., 2001:186). The product-oriented approach aims to choose the correct strategy for the execution of a movement pattern, which is directly aimed at the dynamic system approach of motor learning and control (Markgraaff, 2010:32).
The product-oriented method can further be divided into different approaches (Pienaar, 2014:223-225):
1. cognitive-motor intervention approach;
2. cognitive-strategies based intervention approach; and 3. task-specific intervention approach.
Barnhart et al., (2003:727) explains five reasons why the product-oriented approach may be more successful:
1. This method includes both spatial and motor learning sequences, as well as utilizing the working memory of the child (storing information whilst processing information from another task).
2. The neuronal group selection theory (modern motor development theory). Motor skills appear as a result of:
try-and-fail exploration of nerve groups; selecting the specific neurons in each group;
repetition of synaptic firing in and between the nerve groups; and
sensory experiences.
3. This method provides sufficient motor exercising for neural connections to be established and strengthened.
4. The problem-solving nature of this method allows the child to receive feedback and identify the correct movement pattern.
5. This method allows the basal ganglia and cerebellum to encode motor patterns after long term exercise.
The integrated approach is a combination of both the process-oriented and the product-oriented method. It is most often seen in a multi-disciplinary team (Pienaar, 2014:226).
SUMMARY
In this chapter the researcher identified a gap between research and practise when classifying children with an apraxia disorder and using the correct diagnostic term. Many parents and teachers indicated that children diagnosed with CAS show signs of overall gross motor impairments. Research also indicated that CAS has other co-morbid disorders such as DCD, ADHD and other learning disorders. Furthermore, many types of intervention methods have been promoted, but a consensus were reached about the benefit of early intervention.
CHAPTER THREE METHODOLOGY
INTRODUCTION
Children with Childhood Apraxia of Speech (CAS) have a speech-motor impairment. These children struggle to articulate movements in a co-ordinated, precise and consistent manner by using their mouths and air stream. Parents and clinicians often report body co-ordination problems in children with CAS, which leads to clumsiness (Tükel et al., 2015:1). Research of body co-ordination in children with CAS revealed Developmental Co-ordination Disorder (DCD) to be a co-morbid disorder to CAS because of similar body co-ordination impairments (Gaines & Missiuna, 2006:325). The main area of concern, however, is that motor problems and body co-ordination impairments are under-diagnosed and under-researched in children with CAS (Tükel et al., 2015:1). The current study investigated the gross motor capabilities of children pre-identified with CAS, as well as the effect of a gross motor intervention (implemented in paired- and small groups), on these capabilities.
PROBLEM STATEMENT
The literature review documented in Chapter 2 clearly indicates that the gross motor capabilities of children pre-identified with CAS are under-researched. The proposed study aimed to investigate the gross motor capabilities and the comparative effect of a paired- versus a small group gross motor intervention on selected pre-school children, pre-identified with CAS.
Hypotheses
Null hypothesis (H0):
The outcomes of the gross motor intervention will be the same when the programme is implemented in paired- or small groups.
Research hypothesis (H1):
The outcomes of the gross motor intervention will not be the same when the programme is implemented in paired- or small groups. The programme will have a larger effect when it is presented in paired groups.
MAIN AIM AND OBJECTIVES
Main aim
To compare paired groups to a small group gross motor intervention on the gross motor capabilities of selected pre-school children, pre-identified with CAS’s.
Objective 1
To evaluate the children’s gross motor capabilities.
To asses: manual dexterity; aiming and catching; balance (static and dynamic); locomotor; and object manipulation skills of the selected children.
Objective 2
To compare the effect of a paired groups versus a small group’s gross motor intervention on the gross motor capabilities of the selected children.
To compare the effects of paired groups versus a small group intervention. VARIABLES
Dependent variable:
Gross motor capabilities Independent variable:
Small group intervention Paired intervention Confounding variable:
Environment Evaluators
Researchers (implementing intervention)
RESEARCH DESIGN
Basic research can be divided into two main categories: 1) empirical; and 2) empirical. Empirical research is conducted on real-life issues, whereas non-empirical research is conducted on theories, concepts or statistics (Joubert et al., 2016:26). The current study followed the format of empirical research because the effects of a gross motor intervention on children, pre-identified with CAS, was investigated.
Research can further be divided into quantitative and qualitative research. Quantitative research allows the researcher to systematically quantify a certain aspect, such as movement. Qualitative research, on the other hand, does not focus on numbers but the reasons and beliefs around a certain focus area (Donley, 2012:17, 39). The current study is classified as a quantitative study because the gross motor capabilities studied could be measured and quantified.
In the literature many definitions have been used for different study designs by multiple disciplines. Rockers et al. (2015:512) reviewed literature and summarized the three-class taxonomy of study designs: 1) experimental; 2) quasi-experimental; and 3) non-experimental. The current study followed a quasi-experimental design because the selected participants were not assigned randomly. No control groups were selected, and therefore, the influence on the uncontrollable variables could not be controlled (Joubert et al., 2016:274). The quasi-experimental design evaluates the impact of a certain intervention programme on a target population (Grimshaw et al., 200:11) and to strengthen the design, the participants were randomly divided into the experimental groups (paired groups and a small group) (Rockers et al., 2015:513).
The current study did not follow a specific blinding testing procedure. A double-blind randomized study prevents researchers from being biased and treating participants differently because they do not know to which group the participants belonged to. This protects the study against the Hawthorne effect - the tendency of the participants to act differently if they think they are being singled out (Donley, 2012:19). In the current study, the assessors were blind but the researchers implementing the intervention were able to conclude whether they presented to a group or a pair. Due to the nature of the intervention groups, the participants were also able determine in which intervention group they were participating in. However, the main researcher were blind before data processing. This might lead the testing procedure more to a single-blinded study.
Furthermore, the current study was also based on a comparative effectiveness research design (CER), which focuses mainly on medicine as science. CER is a term that is most commonly used to describe the gathering of data to produce a
comparison between evidence regarding the benefits and harms of alternative approaches to prevent, diagnose, treat and monitor a clinical condition. It is also used to improve the delivery of care and ultimately improve quality of life. The implementation of the CER process has seven steps explained in Table 3.1 (Marko & Weil, 2012:425).
TABLE 3.1: CER’S 7 PROPOSED STEPS AND THE IMPLEMENTATION THEREOF IN THE CURRENT STUDY
CER PROPOSED STEPS IMPLEMENTATION IN CURRENT STUDY
Identifying new interventions. The current study was a novel study. It is also one of the first studies that compares a paired and a small group intervention to each other. Review and generate literature. The current study reviewed literature about
the movement patterns of children with CAS in Chapter 2 which was very vague. During the literature review no studies could be found comparing a small group intervention to a paired intervention.
Identify gaps between research and practice.
The current study identified the gaps in diagnosis, movement patterns and specific types of interventions in Chapter 2.
Encourage and produce new scientific evidence.
A specific gross motor intervention was designed and implemented in a small group and in pairs.
Train and develop researchers. Researchers evaluating and implementing the paired and small group intervention were trained by the main researcher.
Educate others about research findings. The main researcher will publish the findings in accredited, scientific journals.
Share findings with others. The knowledge and findings will be shared with the population group and the parents/teachers of the population group. Adapted from Hastings-Tolsma et al. (2013:685).
Participants
The participants were pre-school (3 to 7 years old) learners from a selected government school in the Bellville area in the Western Cape Province, South Africa, which caters for children pre-identified with CAS by Speech-therapists.
This study followed a non-probability sampling method as the participants represented only a small portion of the population. More specifically, purposive sampling was used because the participants (N=20) were selected based on their characteristics as well as the objective of the study. This made the environment a controlled variable because all the participants were from the same school.
The sample (N=20) included boys (n=18) and girls (n=2), which implied a male:female ratio of 9:1. Tükel et al. (2015:1) alleged that CAS is 3 to 4 times more likely to be diagnosed in boys than girls. The participants in the current study were all in the fundamental movement phase between the ages of 3 and 7 years (pre-school). The fundamental movement phase is characterized by basic movements that has not yet been refined (Yu et al., 2016:134). Participants from diverse socio-economic, as well as different cultural groups, were included.
Each participant received a number and the participants were dived according to their numbers to keep their names anonymous. After the pre-test, the participants were divided randomly into the 2 different groups by an external 3rd party (Prof
Martin Kidd - Director of the Centre for Statistical Consultation at the Stellenbosch University). Prof Martin Kidd used the “rand” function in Microsoft Excel to give each participant a random number. He then used these random numbers to allocate the two different groups. The paired group were further divided into pairs by the main researcher according to their numbers. Therefore, there were 5 paired groups (n=10) and one small group (n=10). The 5 paired groups received the paired and the small group received the small group gross motor intervention. Not all children participated in this study as strict inclusion and exclusion criteria were set. If the child failed to comply with these criteria, he or she was excluded from this study.
